Form 1098-Q Qualifying Longevity Annuity Contract Information

Attention:
Copy A of this form is provided for informational purposes only. Copy A appears in red,
similar to the official IRS form. The official printed version of Copy A of this IRS form is
scannable, but the online version of it, printed from this website, is not. Do not print and file
copy A downloaded from this website; a penalty may be imposed for filing with the IRS
information return forms that can’t be scanned. See part O in the current General
Instructions for Certain Information Returns, available at www.irs.gov/form1099, for more
information about penalties.
Please note that Copy B and other copies of this form, which appear in black, may be
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the recipient.
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forms.

7474

VOID

CORRECTED

ISSUER'S name, street address, city or town, state or province, country, ZIP
or foreign postal code, and telephone no.

ISSUER’S federal identification no. OMB No. 1545-2234
PARTICIPANT’S taxpayer
identification no.

2017

1a Annuity amount on start date

$

Form

1b Annuity start date

3 Total premiums

4 FMV of QLAC

$

$
dd

5b February

dd

5d April

dd

5f June

dd

5h August

dd

5j October

dd

5l December

$
$
$
$
$
$

Form 1098-Q

Copy A
For
Internal Revenue
Service Center
File with Form 1096.
For Privacy Act
and Paperwork
Reduction Act Notice,
see the
2017 General
Instructions for
Certain Information
Returns.

dd

$

5k November
Name of plan

dd

$

5i September
Plan no.

dd

$

5g July

Account number (see instructions)

dd

$

5e May

City or town, state or province, country, and ZIP or foreign postal code

dd

$

5c March
Street address (including apt. no.)

1098-Q

2 Check if start date may be
accelerated

5a January

PARTICIPANT’S name

Qualifying
Longevity Annuity
Contract
Information

dd

$

Plan sponsor's employer
identification no.

Cat. No. 67073Z

Do Not Cut or Separate Forms on This Page

www.irs.gov/form1098q

—

Department of the Treasury - Internal Revenue Service

Do Not Cut or Separate Forms on This Page

CORRECTED (if checked)
ISSUER'S name, street address, city or town, state or province, country, ZIP
or foreign postal code, and telephone no.

ISSUER’S federal identification no. OMB No. 1545-2234
PARTICIPANT’S taxpayer
identification no.

2017

1a Annuity amount on start date

$

Form

3 Total premiums

$
dd

$
dd

5d April

dd

5f June

dd

5h August

dd

5j October

dd

5l December

$
$
$
$

dd
dd

$

5k November

$

Form 1098-Q

dd

$

5i September

Name of plan

dd

This information is
being furnished to
the Internal Revenue
Service.

$

5g July

Plan no.

dd

$

5e May

Account number (see instructions)

5b February

$

5c March

City or town, state or province, country, and ZIP or foreign postal code

Copy B
For Participant

4 FMV of QLAC

$
5a January

Street address (including apt. no.)

1098-Q

2 If checked, start date may
be accelerated

1b Annuity start date

PARTICIPANT’S name

Qualifying
Longevity Annuity
Contract
Information

dd

$

Plan sponsor's employer
identification no.

(Keep for your records)

www.irs.gov/form1098q

Department of the Treasury - Internal Revenue Service

Instructions for Participant
The information on this Form 1098-Q is submitted to the IRS
by the issuer of your qualifying longevity annuity contract
(QLAC) to report the status of the contract. Prior to
annuitization, the value of any QLAC purchased after July 1,
2014, held by your plan or IRA (section 401(a), 403(a), 403(b),
408 (other than a Roth IRA) or eligible governmental plan
under section 457(b)), is not included when calculating the
required minimum distribution (RMD) from your plan or IRA.
You will receive this statement annually beginning with the
first year in which premiums are paid and ending with the
earlier of the year in which you attain age 85 or die. In the
event of your death, if the sole beneficiary under the contract
is your surviving spouse, this annual statement will be
furnished to your surviving spouse until distributions
commence, or if earlier, the year in which your surviving
spouse dies.
If you have questions about your QLAC, contact the issuer
at the address and phone number shown on the front of the
form.
Account number. May show an account or other unique
number the issuer assigned to distinguish your account.
Participant's taxpayer identification number. For your
protection, this form may show only the last four digits of your
social security number (SSN), individual taxpayer identification
number (ITIN), adoption taxpayer identification number (ATIN),
or employer identification number (EIN). However, the issuer
has reported your complete identification number to the IRS.
Plan number, name, and employer identification number.
Shows, if the contract was purchased under a plan, the

number of the plan, the name of the plan, and the employer
identification number (EIN) of the plan sponsor.
Box 1a. Annuity amount on start date. If the payments have
not started, shows the annuity amount payable on start date.
Box 1b. Annuity start date. If the payments have not started,
shows the date on which the annuity is scheduled to start. The
date reported is shown in the format month, day, and year
(mmddyyyy).
Box 2. If checked, shows that the start date may be
accelerated.
Box 3. Shows the cumulative total amount of premiums paid
for the contract. Your cumulative total premiums paid for all
QLACs cannot exceed $125,000. Also, QLACs purchased
under an IRA cannot exceed 25% of your total IRA account
balances and QLACs purchased under an employer's plan
cannot exceed 25% of your account balance in the plan. If
you have paid more than that, contact your contract issuer.
Box 4. Shows the fair market value (FMV) of your QLAC as of
December 31, 2017.
Boxes 5a–5l. Shows the amount of each premium paid for the
contract and the date each premium payment was made in
2017. If there is more than one payment per month, the box
for that month will include the total payments for the month
and the date of the last payment in the month.
Future developments. For the latest information about
developments related to Form 1098-Q and its instructions,
such as legislation enacted after they were published, go to
www.irs.gov/form1098q.

VOID

CORRECTED

ISSUER'S name, street address, city or town, state or province, country, ZIP
or foreign postal code, and telephone no.

ISSUER’S federal identification no. OMB No. 1545-2234
PARTICIPANT’S taxpayer
identification no.

2017

1a Annuity amount on start date

$

Form

3 Total premiums

$
dd

5c March

dd

5d April

dd

5f June

dd

5h August

dd

5j October

dd

5l December

$
5g July
City or town, state or province, country, and ZIP or foreign postal code
Account number (see instructions)

Plan no.

$
Name of plan

Form 1098-Q

dd
dd

For Privacy Act
and Paperwork
Reduction Act
Notice, see the
2017 General
Instructions for
Certain Information
Returns.

$

$
5k November

dd

$

$
5i September

dd

$

$
5e May

5b February

$

$
Street address (including apt. no.)

Copy C
For Issuer

4 FMV of QLAC

$
5a January

1098-Q

2 Check if start date may be
accelerated

1b Annuity start date

PARTICIPANT’S name

Qualifying
Longevity Annuity
Contract
Information

dd

$
dd

$

Plan sponsor's employer
identification no.

www.irs.gov/form1098q

Department of the Treasury - Internal Revenue Service

Instructions for Issuer
To complete Form 1098-Q, use:
• the 2017 General Instructions for Certain Information
Returns, and
• the 2017 Instructions for Form 1098-Q.
To order these instructions and additional forms, go
to www.irs.gov/form1098q.
Caution: Because paper forms are scanned during
processing, you cannot file Forms 1096, 1097, 1098,
1099, 3921, 3922, or 5498 that you print from the IRS
website.

Due dates. Furnish Copy B of this form to the
participant by January 31, 2018.
File Copy A of this form with the IRS by February 28,
2018. If you file electronically, the due date is April 2,
2018. To file electronically, you must have software that
generates a file according to the specifications in Pub.
1220. The IRS does not provide a fill-in form option.
Need help? If you have questions about reporting on
Form 1098-Q, call the information reporting customer
service site toll free at 1-866-455-7438 or 304-263-8700
(not toll free). Persons with a hearing or speech
disability with access to TTY/TDD equipment can call
304-579-4827 (not toll free).